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Type 2 Diabetes Mellitus (T2DM) is a growing health concern that causes considerable morbidity and mortality.1,2


Lower extremity amputations (LEAs) are amongst the most serious and costly complication of T2DM.1,2 Diabetic foot complications, including peripheral vascular disease, neuropathy and structural foot deformities, account for most LEAs.1,3 A multidisciplinary approach aimed at early detection and management of diabetes-related foot complications has been shown to reduce amputation rates by 39-56%.3 Although most diabetes-related LEAs are thought to be largely preventable, the rate of LEAs has risen.1,2

In Australia, rates of diabetes-related LEAs are higher than the global average.1,2 These findings are somewhat surprising given that Australia has a universal health insurance scheme (Medicare) that guarantees all Australians access to a range of health services at low or no cost.4 This raises an interesting question – despite access to and availability of health services, why do LEAs continue to occur in Australia?

To answer this question, we undertook a qualitative descriptive study to explore patients’ perspectives of risk factors for LEAs resulting from T2DM. Competing priorities and awareness were perceived as important risk factors that influenced a patient’s ability to manage their risk of LEAs. Competing priorities included finances and family care. These commitments were perceived to be of higher importance than their own health. Accordingly, patients neglected self-care when they perceived competing priorities existed. In our study, although the median length of diabetes was 26 years and 53% of patients were admitted for their second amputation, awareness was also identified as an important risk. Participants often demonstrated a poor understanding of their condition and were sometimes unaware of the purpose of their treatment, while others were outright critical of the lack of education from healthcare professionals. Some participants perceived that their risk of further complications was reduced once they had recovered from an amputation.

Collectively, this study identifies risk factors that extend beyond the typical biological and modifiable risk factors for LEAs. In understanding patient-perceived risk factors for diabetes-related LEAs, nurses may be better equipped to identify and address factors that impede efforts to prevent LEAs and provide individualised, patient-centred care. This study suggests that competing priorities and awareness may be important issues that need to be addressed.

References
1 Payne CB. Diabetes‐related lower‐limb amputations in Australia. Med J Aust. 2000;173:352-354.
2 Dillon MP, Fortington LV, Akram M, Erbas B, Kohler F. Geographic variation of the incidence rate of lower limb amputation in Australia from 2007-12. PloS one. 2017;12(1):e0170705.
3 Albright RH, Manohar NB, Murillo JF, Kengne LAM, Delgado-Hurtado JJ, Diamond ML, et al. Effectiveness of multidisciplinary care teams in reducing major amputation rate in adults with Diabetes: A systematic review & meta-analysis. Diabetes 3 Research and Clinical Practice. 2020;161:107996.
4 Foster, Michele M., and Geoffrey K. Mitchell. ‘The onus is on me’: Primary care patient views of medicare‐funded team care in chronic disease management in Australia. Health Expectations : an International Journal of Public Participation in Health Care and Health Policy, vol. 18, no. 5, 2015, pp. 879–91

Authors:

Marcelle Ben chmo B Podiatry, Podiatrist at South Australian Local Health Network; University of South Australia Allied Health and Human Performance, University of South Australia; Clinical and Health Sciences, University of South Australia, Australia.

Lisa Matricciani PhD, M (Nursing), B Nursing, B Podiatry, Cert (pediatrics), University of South Australia Allied Health and Human Performance, University of South Australia; Clinical and Health Sciences, University of South Australia, Australia.

Associate Professor Saravana Kumar PhD, M PHTY (manipulative & sports), GRAD DIP (digital learning), B APP SC (Physio), University of South Australia Allied Health and Human Performance, University of South Australia; Clinical and Health Sciences, University of South Australia, Australia.

Dr Kristin Graham PhD Medicine (Centre for Traumatic Stress Studies, The University of Adelaide), B Psychological SC (Honours), Dip App Sc (Podiatry), University of South Australia Allied Health and Human Performance, University of South Australia; Clinical and Health Sciences, University of South Australia, Australia.